Doctors Report Rise in Elective Caesareans

By SUSAN GILBERT

Published: September 22, 1998

THE Manhattan woman was in the first trimester of pregnancy with her first child when she decided how she wanted the baby delivered. She had read about childbirth in pregnancy books, heard war stories from friends and relatives and feared that she could not endure whatever labor pain she might have before the epidural kicked in. She told her doctor that when her pregnancy was full term, she wanted a Caesarean section.

''I spent a long time counseling her,'' said Dr. Andrei Rebarber, her obstetrician at New York University Medical Center. He told her that she had a greater chance for complications, including hemorrhage, infection and death, from a Caesarean section than from vaginal delivery. ''I told her I won't do a Caesarean section without a medical indication. I feel that it's unethical.''

But the woman, a 46-year-old credit manager who spoke on the condition that her name not be published, saw the situation differently. ''I was surprised it wasn't my choice,'' she said. ''It's my body.''

She said that she was willing to pay the extra cost of a surgical delivery if her insurance company did not cover it. Now five months pregnant, the woman has been trying to decide once and for all whether to stay with Dr. Rebarber, whom she respects, or switch to a doctor who will honor her choice.

Needless to say, this woman's request is unusual. For years, pregnant women's choice has been synonymous with the most natural childbirth possible. And it has been a consensus among medical professionals that many Caesareans are unnecessary, with a rate of about 21 percent of all births in this country, down slightly from a record high of nearly 25 percent in 1988 and far higher than the 5 percent of 1965. Hospitals and medical groups pressure doctors to avoid doing Caesareans unless there is medical justification, like failure of labor to progress or signs of distress to the fetus. The Department of Health and Human Services has the goal of lowering the rate to 15 percent by 2000.

But the pendulum is beginning to swing, slightly, in the other direction. Though no figures exist for elective Caesareans, some doctors say that more women are asking for C-sections, even when they are not necessary. And doctors are sharply divided on how to respond.

Several recent reports that question the safety of vaginal deliveries in certain circumstances are driving this turnaround. For example, in May, the Food and Drug Administration issued a public health advisory on vacuum-assisted delivery devices, tools that are sometimes used for difficult vaginal births. Each year for the last four years in the United States, according to the advisory, five newborns have died or been seriously injured after delivery with these devices.

Another report concerned the safety of vaginal delivery for women who previously had Caesareans. Though doctors have encouraged such women to try to deliver vaginally, a large Canadian study published two years ago found that the chance of major complications to the mother were greater than previously shown: nearly twice as great as from a Caesarean section that was scheduled before labor.

In general, childbirth is considered extremely safe for both mother and child. Still, the findings on vaginal deliveries have left some doctors questioning whether the Caesarean section rate really is too high and some women wondering whether it is worth the pain and uncertainty of going through labor when scheduled surgery is so convenient.

''The assumption that our C-section rate is too high is based on zero data,'' said Dr. Charles Lockwood, an obstetrician at New York University Medical Center and a member of the committee of obstetrical practice of the American College of Obstetricians and Gynecologists. Lowering the C-section rate to 15 percent, he said, ''may be dangerous.''

In England, there has been a marked increase in the number of women asking for Caesareans when they are not medically necessary, according to two commentaries in the British Medical Journal last month. The authors offered several reasons: medical advances like local anesthesia that have made Caesarean sections safer, and evidence that long, difficult vaginal deliveries can cause ''substantial morbidity,'' like stress incontinence and other pelvic damage to the mother, and cerebral palsy or even death to the baby.

''We are at a turning point in obstetric thinking,'' said Dr. Sara Paterson-Brown, an obstetrician and gynecologist at Queen Charlotte's and Chelsea Hospital in London and an author of one commentary. ''I'm not saying that Caesarean section is good and vaginal delivery is bad, but there's increased evidence that the picture is no longer black and white.''

Elective Caesareans in England have increased to 6.5 percent of C-sections in 1995 from 4 percent in 1980, said Dr. Robert Kyffin, a research fellow with the Royal College of Obstetricians and Gynecologists in Manchester. Overall, England's Caesarean rate has increased to 16 percent, up from 10.4 percent in 1985.